RENAL%20FAILURE - PowerPoint PPT Presentation

About This Presentation



In the U.S. The US Renal Data System (USRDS) has shown a dramatic increase in ... Excess fluid volume r/t decreased urine output, and retention of sodium and water ... – PowerPoint PPT presentation

Number of Views:1610
Avg rating:3.0/5.0
Slides: 111
Provided by: Meli305
Tags: 20failure | renal | legs | us


Transcript and Presenter's Notes


  • Melissa Greer, Ylise Dobson,
  • Megan Stacey, Melissa Terpstra,
  • Emily Peterson

The Radical Renal Team
  • Dr. McCurly

The Radical Renal Team
  • The Nurses
  • McTall McShorty

The Radical Renal Team
  • The Nurses
  • McSmall McGiant

Case Study
Tia Smith is a 26 year old female patient who is
10 hours post-partum following an emergency
C-section for twins. She was 33.5 weeks pregnant
and had a difficult pregnancy with PIH (pregnancy
induced hypertension) and frequent urinary tract
infections. On admission Tia was diagnosed with
HELLP syndrome (hemolysis, elevated liver
enzymes, low platelets) which necessitated
immediate delivery of her babies. During the
C-section Tia became hypovolemic resulting from
massive hemorrhaging and required blood products
and fluid replacements. Tia eventually developed
hypovolemic shock and remained unstable for 2
hours. For the past nursing shift Tia has been
hypotensive with blood pressures ranging from
59/47 to 95/52. Tias urinary output has been
2-12cc/hr of brown cloudy foul smelling urine.
During your morning assessment you discover the
Case contd
  • VS T 37.4 P 125bpm R 33 BP 96/62
  •  Respiratory Chest is clear fine crackles heard
    throughout all lung fields, there is diminished
    A/E at the bottom of the R L lobes
  •  CV S1, S2 audible with pericardial friction,
    bounding rapid pulse
  •  Mental Status drowsy and with assistance will
    orient slowly to PPT, pt c/o persistent hiccups
  •  Neurovascular edema, skin cool pale, bruises
    observed throughout extremities, skin turgor
    poor, bilateral decreased sensation in feet
  •  GI pt c/o NV
  •  Genitourinary pt has foley catheter draining
    brown cloudy foul smelling urine at 2-12cc/hr
  •  Psychosocial pt very emotional and crying at
    times because she cannot be with her newborn
    babies and is unable to breastfeed, she is
    concerned for their health, and does not
    understand how this happened to her

So What is Tias diagnosis?
Acute Renal Failure
Anatomy of the Kidney
10 Functions of the Kidneys
  • Urine Formation Formed in the nephrons through a
    complex three-step process GF, tubular
    reabsorption, and tubular secretion
  • Excretion of waste products eliminates the
    bodys metabolic waste products (urea,
    creatinine, phosphates, sulfates)
  • Regulation of electrolytes volume of
    electrolytes excreted per day is exactly equal to
    the volume ingested
  • Na allows the kidney to regulate the volume of
    body fluids, dependent on aldosterone (fosters
    renal reabsorption of Na)
  • K kidneys are responsible for excreting more
    than 90 of total daily intake

Renin-Angiotensin System
Kidney Function contd
  • Regulation of acid-base balance elimination of
    sulphuric and phosphoric acid

Kidney function contd
  • Control of water balance Normal ingestion of
    water daily is 1-2L and normally all but
    400-500mL is excreted in the urine
  • Osmolality degree of dilution or concentration
    of urine (particles dissolved/kg urine (glucose
    proteins are osmotically active agents)
  • Specific Gravity measurement of the kidneys
    ability to concentrate urine (weight of particles
    to the weight of distilled water)
  • ADH vasopressin regulates water excretion and
    urine concentration in the tubule by varying the
    amount of water reabsorbed.

Still talking about kidney function
  • Control of blood pressure BP monitored by the
    vasa recta.
  • Juxtaglomerular cells, afferent arteriole, distal
    tubule, efferent arteriole http//www.wisc-online
  • Renal clearance ability to clear solutes from
  • Dependent on rate of filtration across the
    glomerulus, amount reabsorbed in the tubules,
    amount secreted into the tubules
  • Regulation of red blood cell production
    Erythropoeitin is released in response to
    decreased oxygen tension in renal blood flow.
    This stimulates the productions of RBCs
    (increases amount of hemoglobin available to
    carry oxygen)

Kidney function contd
  • Synthesis of vitamin D to active form final
    conversion of vit D into active form to maintain
    Ca balance
  • Secretion of prostaglandins important in
    maintaining renal blood flow (PGE PGI). They
    have a vasodilatory effect

Timeline of Events
  • A syndrome featuring a combination of "H" for
    hemolysis (breakage of red blood cells), "EL" for
    elevated liver enzymes, and "LP" for low platelet
    count (an essential blood clotting element).
  • PREGNANCY COMPLICATION - occurring in 25 of
    pregnancies with toxemia or pre-eclampsia.
  • Symptoms include-
  • Shortness of breath
  • H/A
  • Dimmed vision
  • Nausea
  • Dizziness Fainting
  • Edema
  • Pain in the upper abdomen

Effects of HELLP on Mom Baby
  • Mothers with HELLP are at increased risk for
  • Liver rupture, DIC, abruptio placentae, and acute
    renal failure, stroke, seizure, ARD, pulmonary
  • 1st order of tx is management of blood clotting
  • Women with a hx of HELLP are considered at risk
    for future pregnancies
  • After delivery, mothers vitals are CLOSELY
    monitored to observe for complications

Acute Renal Failure
  • Acute renal failure (ARF) is an abrupt and sudden
    reduction in renal function resulting in the
    inability to excrete metabolic wastes and
    maintain proper fluid electrolyte balance
  • It is usually associated with oliguria (urine
    output lt30cc/hr or lt400cc/day), although urine
    output may be normal or increased
  • BUN creatinine values are elevated

Statistics of ARF
  • Frequency condition develops in 5 of
    hospitalized patients and 0.5 patients require
  • Elderly are at high risk
  • Post-op patients
  • Mortality the mortality rate estimates vary from
  • Race no racial predilection is recognized

  • ARF may occur in 3 clinical settings
  • As an adaptive response to severe volume
    depletion and hypotension, with structurally and
    functionally intact nephrons (Prerenal)
  • In response to cytotoxic or ischemic insults to
    the kidney, with structural and functional damage
    (Intrinsic or Intrarenal)
  • Obstruction to the passage of urine (Postrenal)

Phases of Acute Renal Failure
  • Clinical progression of reversible RF occurs in
    four phases
  • Initiation phase
  • Begins with initial insult and ends when oliguria
  • Oliguric phase
  • Accompanied by rise in serum concentrations of
    substances usually excreted by kidneys (urea,
    creatinine, ua, organic acids, intracellular
    cations K Mg)
  • urinary output lt400cc/day
  • May last 1-3 weeks
  • Diuretic phase
  • The kidneys begin to recover
  • Initially produce hypotonie urine d/t increase in
  • Recovery phase
  • Tubular function restored
  • Diuresis subsides and kidney begins to function
    normally again

Prerenal acute renal failure
  • Is the most common cause of ARF occurring in
    60-70 of cases
  • It is caused by impaired blood flow as a result
    of intravascular depletion, which leads to
    decreased effective circulating volume to the
  • In patients with prerenal ARF, the parenchymal is
    undamaged, and the kidneys respond as if volume
    depletion has occurred.

Prerenal ARF
  • Causes include
  • Secondary to renal hypoperfusion which occurs in
    setting of extracellular fluid loss
  • Diarrhea
  • Vomiting
  • Diuretics
  • Impaired/inadequate cardiac output
  • Drugs
  • NSAIDs
  • ACE Inhibitors
  • Hypovolemia
  • Hemorrhage
  • Renal vasoconstriction

Intrinsic acute renal failure
  • Is the result of actual parenchymal damage to the
    glomeruli or kidney tubules
  • A physiologic hallmark is failure to maximally
    concentrate urine
  • Is divided into 4 categories
  • Acute tubular disease
  • Glomerular disease
  • Vascular disease
  • Interstitial disease

Intrinsic ARF
  • Acute Tubular Necrosis
  • most common type of ARF, a more ischemic insult
    to the kidneys, usually induced by ischemia or
  • Caused by
  • Burns, and crush injuries myoglobin
    hemoglobin are liberated causing renal toxicity
    or ischemia
  • Drugs NSAIDs, ACE inhibitors, aminoglycosides
  • Infections
  • Nephrotoxic agents contrast agent
  • Glomerulonephritis
  • uncommon cause, most associated with CRF
  • Caused by
  • Can be a primary disorder or can occur secondary
    to systemic disease
  • Systemic lupus erythematosus

Intrinsic ARF
  • Acute Interstitial Nephritis
  • Interstitial disturbance that leads to ARF
  • Caused by
  • Allergic reaction to drugs
  • Vascular Disease
  • Can occur on microvascular and macrovascular
  • Caused by
  • Microvascular
  • Hemolytic anemia
  • ARF secondary to small vessel thrombosis or
  • Macrovascular
  • Suspected in elderly
  • Renal artery stenosis or thrombosis
  • Atheroembolism secondary to atrial fibrillation
    and aortic disease

Postrenal acute renal failure
  • Is rare and occurs with urinary tract obstruction
    that affects the kidneys bilaterally
  • Pressure rises in the kidney tubules, eventually
    the GFR decreases

Postrenal ARF
  • Causes include
  • Bladder tract obstruction
  • Prostatic hypertrophy
  • Catheters
  • Neurogenic bladder
  • Postrenal causes are typically reversible

  • History
  • Observe for disorder that predisposes pt to ARF
  • Ask questions about recent illness, infections,
    or injuries
  • Medication history
  • Urinary patterns
  • History of GI problems
  • Psychosocial
  • Anxious
  • Family members

Clinical Manifestations of ARF
  • Cardiovascular
  • Arrhythmias
  • BP, N, high or low
  • Anemia
  • P, rapid, bounding, or N
  • Pericardial-type chest pain
  • Respiratory
  • Dyspnea
  • Crackles
  • Tachypnea
  • Kussmauls respirations
  • Mental Status
  • Lethargy
  • Tremors
  • Memory loss
  • Confusion
  • Musculoskeletal
  • Muscle spasms
  • Weakness
  • Genitourinary
  • Oliguria
  • Anuria
  • abN urine colour, clarity, smell
  • GI
  • Moist tongue increased saliva
  • Dry tongue mucous membranes
  • NV
  • Integumentary
  • Moist, warm skin pitting edema
  • Decreased skin turgor
  • bruises
  • Pallor
  • Thin, brittle hair nails

Nursing Care Plan
  • Fluid volume deficit related to hemorrhage
    (hypovolemic shock)
  • Priority to restore fluid balance and circulation
  • The patient will
  • show stable vital signs
  • have adequate urine output gt30cc/hr
  • have strong peripheral pulses indicating tissue
  • display LOC normal for patient

Nursing Care Plan
  • Interventions
  • Bleeding reduction, fluid resuscitation, blood
    product administration, IV therapy
  • Monitor VS q2h
  • Monitor weight daily
  • Skin tongue turgor
  • Monitor and document IO
  • Monitor CBC, ABG, urinalysis, ECG
  • Rationales
  • Early intervention can prevent progression of
    hypovolemia to hypovolemic shock that may result
    in renal damage
  • SS correlate with the approximate percentage of
    volume loss
  • Medullary vasomotor center stimulation via the
    baroreceptor reflex
  • ADH
  • Foley catheter facilitates monitoring of urine
  • Shock pt hemodynamically unstable with
    compromised compensatory mechanisms, volume admin
    may cause fld overload

Nursing Care Plan
  • Electrolyte imbalance related to decreased
    electrolyte excretion, and metabolic acidosis
  • Priority to prevent complications of electrolyte
  • Within 24h of admission and then continuously,
    the pt will
  • Maintain serum electrolyte levels within
    acceptable limits
  • Have normal sinus rhythm

Nursing Care Plan
  • Interventions
  • Monitor document electrolyte levels q8-12h,
  • K, P, Ca, Mg
  • Monitor ABG
  • Monitor ECG especially
  • High tented T waves, prolonged PR interval or
    widened QRS complex
  • Limit dietary drug intake of potassium
  • Rationales
  • Kidneys ability to regulate electrolyte
    excretion reabsorption may result in high K
    P, low Ca, high/low Mg levels.
  • ARF causes metabolic acidosis which may increase
    the release of K from cells in exchange for H
  • Electrolyte abN can trigger arrhythmias cardiac
  • When kidneys cannot excrete K, excess intake can
    increase serum K to dangerous levels

Nursing Care Plan
  • Knowledge deficit of acute renal failure related
    to lack of exposure to information on management
    of complex condition
  • Priority to provide in depth information on acute
    renal failure
  • Upon discharge the patient will
  • Be able to identify signs and symptoms to report
    to nurse or physician
  • Commitment to comply with treatments, including
    dialysis, dietary modifications, and activity

Nursing Care Plan
  • Interventions
  • Provide as appropriate information on the
    severity of ARF dialysis
  • Stages of ARF
  • Medications including action and adverse effects
  • SS
  • Procedures such as dialysis including schedule
    and adverse effects
  • Dietary modifications including limitations of
    proteins (catabolism), electrolytes and fluids
  • Rest and activity restrictions
  • Rationales
  • The patient and family need assistance,
    explanation, and support during this time.
  • Teaching may decrease anxiety and fear, and
    enhance recovery to patient and family members.
  • Continued assessment of the patient for
    complications of ARF and of its precipitating
    cause is essential.

Acute Renal Failure

Medications for ARF
  • Pharmacologic treatment of ARF has been attempted
    on an empirical basis, with varying success
    rates. Several promising experimental therapies
    in animal models are awaiting human trials
  • It is critical to adjust (decrease or
    discontinue) medication dosages for patient in
    acute renal failure. Administering the average
    dose to patient in renal failure can kill a

Medications for ARF continued
  • Immediate goal is to retain fluid volume deficit
    through use of blood products and crystalloids
  • Normal Saline (0.9 Na) only one that is
    compatible with blood transfusions
  • Restores fluid loss
  • Provides electrolytes resembling those of plasma
  • Packed RBC
  • To increase blood volume
  • To restore blood to kidneys

Medications for ARF continued
  • Diuretics
  • Furosemide (Lasix) only given with severe fluid
  • Increases excretion of water by interfering with
    chloride-binding cotransport system, which, in
    turn, inhibits sodium and chloride reabsorption
    in the thick ascending loop of Henle and the
    distal renal tubule
  • Adult dose 20-80 mg PO/IV once repeat 6-8h prn
    or dose may be increased by 20-40 mg no sooner
    than 6- 8h after previous dose until desired
  • Nursing Assessments Watch for hypokalemia,
    assess BP before and during therapy can cause

Medications for ARF continued
  • Vasodilators
  • Dopamine
  • In small doses causes selective dilatation of the
    renal vasculature, enhancing renal perfusion.
  • Reduces sodium absorption, thereby decreasing the
    energy requirement of the tubules. This enhances
    urine flow, which, in turn, helps prevent tubular
    cast obstruction.
  • Adult dose 2-5 mcg/kg/min
  • Nursing Assessments Monitor BP during
    administration, stop infusion if BP drops 30mm
    Hg, Monitor IO

Medications for ARF continued
  • Alkalinizer
  • Sodium Bicarbonate
  • Increases plasma bicarbonate, which buffers
    Hydrogen ion concentration reverses acidosis
  • Adult Dose Initial dose IV bolus 1 mEq/kg, then
    infuse 2-5 mEq/kg over 4-8 hr depending on CO2,
  • Dilute with equal amounts of NS, 2-5 mEq/kg
  • Nursing assessments Assess resp. and pulse rate,
    rhythm, depth, lung sounds, monitor IO,
    electrolytes, blood pH, PO2, HCO3, monitor urine
    pH, and UO during beginning of treatment, monitor
    for alkalosis, monitor ABGs and blood studies

13 have passed and now Tia is diagnosed with
  • Chronic Renal Failure
  • 13 years have passed ? Tia is now 39 years of age
    and has been experiencing declining renal
    function over the past 13 years. Tia has lost
    15lbs on her already small frame, she feels
    generally ill most of the time with frequent NV,
    she suffers from fatigue, muscle twitching
    cramps decreased sensation in her hands and feet
    and generalized puritus. The Physician has
    diagnosed Tia with ESRD and has determined that
    long term dialysis will be required.

  • Chronic Renal Failure
  • ESRF

  • Also known as End-Stage Renal Failure (ESRF), is
    a progressive deterioration in renal function in
    which the bodys ability to maintain metabolic
    and fluid and electrolyte balance fails,
    resulting in uremia (retention of urea and other
    nitrogenous wastes in the blood).
  • decreased kidney glomerular filtration rate (GFR)
    of lt60 mL/min/1.73 m2 for 3 or more months

  • In the U.S. The US Renal Data System (USRDS) has
    shown a dramatic increase in patients with CRF
    who require chronic dialysis or transplantation.
    In 1999, there were 340,000 such patients, but,
    by 2010, this number is projected to reach
  • Internationally The incidence rates of end-stage
    renal disease (ESRD) have increased steadily
    internationally since 1989. The United States has
    the highest incident rate of ESRD, followed by
    Japan. Japan has the highest prevalence per
    million population, with the United States taking
    second place.

Statistics Contd
  • Mortality /Morbidity CRF is a major cause of
    morbidity and mortality, particularly at the
    later stages. The 5-year survival rate for a
    patient undergoing chronic dialysis is
    approximately 35. This is approximately 25 in
    patients with diabetes. The most common cause of
    death in the dialysis population is
    cardiovascular disease.
  • Race Affects all races

  • As renal function declines, the end products of
    protein metabolism (which are normally excreted
    in the urine), accumulate in the blood. Uremia
    develops and adversely effects every system in
    the body.
  • The greater the buildup of waste products, the
    more severe the symptoms.
  • Approximately 1 million nephrons are present in
    each kidney, each contributing to the total GFR.
    Regardless of the etiology of renal injury, with
    progressive destruction of nephrons, the kidney
    has an innate ability to maintain GFR by
    hyperfiltration and compensatory hypertrophy of
    the remaining healthy nephrons.
  • This nephron adaptability allows for continued
    normal clearance of plasma solutes such that
    substances such as urea and creatinine start to
    show significant increases in plasma levels only
    after total GFR has decreased to 50, when the
    renal reserve has been exhausted. The plasma
    creatinine value will double with a 50 reduction
    in GFR.

Stages of Chronic Renal Disease
  • 3 stages in nephron function
  • Stage 1 Reduced Renal Reserve
  • Characterized by a 40-75 loss of nephron
    funtion. The patient is usually asymptomatic
    because the remaining nephrons are able to carry
    out normal function of the kidney

Stage 2 of Renal Disease
  • Stage 2 Renal Insufficiency
  • Occurs when 75-90 of nephron function is lost.
    At this point, the serum creatinine and BUN rise,
    the kidney loses its ability to concentrate urine
    and anemia develops. The patient may report
    polyuria and nocturia

Stage 3 of Renal Disease
  • Stage 3 End-Stage Renal Disease
  • The final stage, occurs when there is less than
    10 of nephron function remaining. All normal
    regulatory, excretory, and hormonal functions of
    the kidneys are severely impaired. ESRD is
    evidenced by elevated creatinine and BUN levels
    as well as electrolyte imbalances.
  • Dialysis is usually indicated at this point.

Glomular Filtration Rate
  • GFR a Kidney function test in which results can
    be determined from amount of ultrafiltrate formed
    by plasma flowing through the glomeruli of the
  • As glomular filtration decreases, the serum
    creatinine and BUN levels increase.

  • Type 1 and type 2 diabetes mellitus cause a
    condition called diabetic nephropathy, which is
    the leading cause of kidney disease in the United
  • High Blood Pressure (hypertension), if not
    controlled, can damage the kidneys over time.
  • Glomerulonephritis is the inflammation and damage
    of the filtration system of the kidney and can
    cause kidney failure. Postinfectious conditions
    and Lupus are among the many causes of

More Causes
  • Polycystic Kidney Disease is an example of a
    hereditary cause of chronic kidney disease
    wherein both kidneys have multiple cysts 
  • Use of analgesics such as acetaminophen (Tylenol)
    and ibuprophen regularly over long durations of
    time can cause analgesic nephropathy, another
    cause of kidney disease. Certain other
    medications can also damage the kidneys.
  • Clogging and hardening of the arteries
    (atherosclerosis) leading to the kidneys causes a
    condition called ischemic nephropathy, which is
    another cause  of progressive kidney damage.
  • Obstruction of the flow of urine such as by
    stones, an enlarged prostate, strictures
    (narrowings), or cancers may also cause kidney

Clinical Manifestation
  • Patients with CRF stage 3 or lower (GFR gt30
    mL/min) generally are asymptomatic and do not
    experience clinically evident disturbances in
    water or electrolyte balance or
    endocrine/metabolic disturbances.
  • Generally, these disturbances clinically manifest
    with CRF stages 4 and 5 (GFR lt30 mL/min).

Clinical Manifestations
  • Hyperkalemia usually develops when GFR falls to
    less than 20-25 mL/min because of the decreased
    ability of the kidneys to excrete potassium.
  • Metabolic acidosis because the kidney cannot
    excrete increased loads of acid.

Clinical Manifestations
  • Extracellular volume expansion and total-body
    volume overload results from failure of sodium
    and free water excretion.
  • Anemia principally develops from decreased renal
    synthesis of erythropoietin, the hormone
    responsible for bone marrow stimulation for red
    blood cell (RBC).
  • Calcium and Phosphorus imbalance occurs because
    of a disorder in metabolism. They have a
    reciprocal relationship in the body as one
    rises, the other decreases.

Signs and Symptoms
  • Neurologic
  • weakness, fatigue, confusion, disorientation,
    tremors, seizures, restlessness of legs, burning
    of soles of feet, behavioral changes.
  • Integumentary
  • Gray-bronze skin colour, dry, flaky skin,
    pruritus, ecchymosis, thin brittle nails, coarse,
    thinning hair
  • Pulmonary
  • Crackles, thick tenacious sputum, depressed cough
    reflex, pleuritic pain, shortness of breath,
    engorged neck veins, tachypnea, uremic
    pneumonitis, uremic lung
  • Gastrointestinal
  • Ammonia odour to breath, metallic taste, mouth
    ulcerations and bleeding, anorexia, NV, hiccups,
    constipation or diarrhea, bleeding from GI tract.
  • Hematologic
  • Anemia, thrombocytopenia
  • Musculoskeletal
  • Muscle cramps, loss of muscle strength, renal
    osteodystrophy, bone pain, bone fractures, foot

Nursing Care Plan
  • Rationale
  • Assessment provides baseline and ongoing database
    for monitoring changes and evaluating
  • Fluid restriction will determine on the basis of
    weight, urine output, and response of therapy
  • Understanding promotes pt and family cooperation
    with fluid restrictions
  • Oral hygiene minimizes dryness of oral mucous
  • Expected Outcomes
  • Demonstrates no rapid weight changes
  • Maintains dietary and fluid restrictions
  • Exhibits normal skin turgour without edema
  • Normal vitals
  • Reports no difficulty breathing or shortness of
  • Reports decrease dryness of oral mucous
  • Excess fluid volume r/t decreased urine output,
    and retention of sodium and water
  • Goal is maintenance of ideal body weight without
    access fluid
  • Nursing Interventions
  • Assess fluid Status
  • Daily weight
  • I O
  • Skin turgour edema
  • Distention of neck veins
  • BP, P, R
  • Limit fluid intake to prescribed volume
  • Explain to pt and family rationale for
    restriction of food
  • Provide or encourage frequent oral care

Nursing Care Plan
  • Hyperkalemia, pericarditis, pericardial effusion
    and temponade, hypertension, anemia, bone disease
  • Goal Patient experiences and absence of
  • Nursing Interventions
  • Hyperkalemia
  • Monitor serum K levels and notify physician if
    greater than 5.5 mEq/L.
  • Assess patient for muscle weakness, diarrhea, ECG
    changes( tall tented Twaves, widened QRS).
  • Rationale
  • Hyperkalemia causes potentially life-threatening
    changes to the body
  • Cardiovascular S S are characteristic of
  • Expected Outcomes
  • Pt has normal K level
  • Experiences no muscle weakness or diarrhea,
  • Exhibits normal ECG pattern
  • Vital signs are within normal limits

  • Pericarditis, Pericardial effusion, tamponade
  • Assess for fever, chills, chest pain and
    pericardial friction rub (signs of pericarditis).
  • If pt has pericarditis, ax q 4 hrs
  • Extreme hypotension
  • Weak of absent peripheral pulses, altered level
    of consciousness, bulging neck veins.
  • Rationale
  • About 30-50 of CRF pts develop pericarditis due
    to uremia fever ,chest pain, and pericardial
    friction rub are classic signs
  • Pericardial effusion is common following
    pericarditis. Signs of effsusion paradoxical
    pulse (gt 10 mm drop in BPduring inspiration) and
    signs of shock d/t compression of the heart by a
    lg effusion.
  • Cardiac tamponade exists when the pt is severely
    compromised hemodynamically
  • Outcomes
  • Has strong and equal peripheral pulse
  • Absence of paradoxical pulse
  • Absence of pericardial effusion, or tamponade

  • Hypertension
  • Monitor and record blood pressure
  • Administer antihypertensives as prescribes
  • Encourage compliance with dietary and fluid
    restriction therapy
  • Teach pt report signs of fluid overload, vision
    changes, headaches, edema, seizures
  • Rationale
  • Antihypertensives play a key role in tx of
    hypertension associated with CRF.
  • Adherence to diet and fluid restrictions prevents
    excess fluid and sodium accumulation
  • These are indications of inadequate control of
    hypertension, and need to alter therapy
  • Outcomes
  • BP is within normal limits
  • No headaches, visual problems or seizures
  • No edema
  • Demonstrates compliance with dietary and fluid

  • Anemia
  • Monitor RBC count, Hg, and HCT levels
  • Administer prescribes meds iron and folic acid
  • Avoid drawing unnecessary blood specimens
  • Teach pt to prevent bleeding avoid vigorous nose
  • Administer blood component therapy
  • Rationale
  • Provides Ax of degree of anemia
  • RBCs need iron and folic acid to be produced.
  • Anemia is worsened by drawing numerous specimens
  • Blood component therapy may be needed if pt has
  • Outcomes
  • Pt has normal colour without pallor
  • Hematology values are within acceptable limits
  • Experiences not bleeding form any site.

  • Bone Disease
  • Administer the following meds as prescribed
    phosphate binders, calcium supplements, vit D
  • Monitor serum lab values ( calcium, phosphorus,
  • Assist pt with exercise program
  • Rationale
  • CRF causes numerous physiologic changes affecting
    calcium, phosphorus and vit D metabolism.
  • Hyperphophatemia, hypocalcemia, and excess
    aluminum accumulation are common
  • Bone demineraliztion decreases with immobility.
  • Outcomes
  • Serum calcium, phosphorus, and aluminum levels
    are within acceptable ranges.
  • Has no bone demineralization
  • Discuss importance of maintaining activity level
    and exercise program.

  • Protein restriction b/c urea, uric acid and
    organic acids- the breakdown product of dietary
    and tissue proteins- accumulate rapidly in the
    blood when there is impaired renal clearance.
  • The allowed protein must be of high biologic
    value (diary products, eggs, meats). These
    proteins are those that are complete proteins and
    supply the essential amino acids necessary for
    cell growth and repair also maintenance of fluid
    balance, healing and skin integrity, and
    maintenance of immune function.
  • Fluid restrictions fluid allowance is usually
    500-600 ml more than the previous days 24 hr
  • Calories are supplied by carbs and fats to
    prevent wasting and malnutrition
  • Vitamin supplementation because a protein
    restricted diet does provide the necessary
    amounts of vitamins and the pt on dialysis may
    lose water soluble vitamins from the blood during

Chronic Renal Failure

Medications for CRF
  • Diuretics
  • Furosemide (Lasix) only given with severe fluid
  • Increases excretion of water by interfering with
    chloride-binding cotransport system, which, in
    turn, inhibits sodium and chloride reabsorption
    in the thick ascending loop of Henle and the
    distal renal tubule
  • Adult dose 20-80 mg PO/IV once repeat 6-8h prn
    or dose may be increased by 20-40 mg no sooner
    than 6-8h after previous dose until desired
  • Nursing Assessments Watch for hypokalemia,
    assess BP before and during therapy can cause

Medications for CRF continued
  • Phosphate-lowering agents
  • Calcium acetate (Calphron, PhosLo)
  • Combines with dietary phosphorus to form
    insoluble calcium phosphate, which is excreted in
  • Adult dose 1-2 g PO bid-tid with each meal
    increase to bring serum phosphate value to 6
    mg/dL as long as hypercalcemia does not develop
  • Calcium carbonate (Caltrate, Apo-Cal, Tums)
  • Successfully normalizes phosphate concentrations
  • Neutralizes gastric acidity, increase serum Ca
  • Adult dose 1-2 g PO divided bid-tid with meals
    as a phosphorous binder between meals as a
    calcium supplement

Phosphate-lowering agents
  • Calcitriol (Rocaltrol, Calcijex)
  • Increases intestinal absorption of calcium for
    treatment of hypocalcemia and increases renal
    tubular resorption of phosphate
  • Adult dose for hypocalcemia during chronic
  • 0.25 mcg/day or every other day, may require
    0.5-1 mcg/day PO
  • Sevelamer (Renagel)
  • Indicated for the reduction of serum phosphorous
    in patients with ESRD.
  • Adult dose Initial 800-1600 mg PO tid with
    mealsMaintenance Increase or decrease by
    400-800 mg per meal q2wk to maintain serum
    phosphorous at 6 mg/dL or less

Phosphate-lowering agents
  • Lanthanum carbonate (Fosrenal)
  • for reduction of high phosphorus levels in
    patients with ESRD
  • Adult dose Initial 250-500 mg PO tid pc
    (chewable tabs) adjust dose q2-3wk to target
    serum phosphorus levelMaintenance 500-1000 mg
    PO tid pc

Phosphate-lowering agents
  • Doxercalciferol (Hectorol)
  • To lower parathyroid hormone levels in patients
    undergoing chronic kidney dialysis. Increases
    serum Ca
  • Adult dose 10 mcg PO 3 times/wk at dialysis
    increase dose by 2.5 mcg/8 wk if iPTH is not
    lowered by 50 and fails to reach the target
    range not to exceed 20 mcg/3 times/wkAlternative
    ly, 4 mcg IV 3 times/wk may adjust dose by 1-2
    mcg/8 wk to maintain iPTH levels
  • Nursing Assessment for all phosphate lowering
    agents Monitor BUN, creatinine, chloride,
    electrolytes, urine pH, urinary calcium, mg,
    phosphate, urinalysis urinary Ca should be
    9-10mg/dl, assess for hypocalcemia headache,
    N/V, confusion

Medications for CRF continued
  • Anemia
  • Epoetin alfa (Epogen, Procrit)
  • Stimulates RBC production
  • Adult dose 50 -150 U/kg IV/SC 3 times per week,
    then adjust dose by 25 U/kg/dose to maintain
    appropriate Hct maintenance 12.5-25 U/kg,
    titrate to target Hct,
  • Nursing Assessment Monitor renal studies
    urinalysis, protein, blood, BUN, creatinine IO.
    Monitor blood studies, Hgb, Hct, RBC, WBC, INR,

Medications for CRF continued
  • Darbepoetin (Aranesp)
  • Stimulates erythropoiesis
  • Adult dose 0.45 ug/kg IV/SC as a single
    injection, titrate not to exceed a target Hgb of
    12 g/dl
  • Has a longer half-life than epoetin alfa
  • Nursing Assessments Assess blood studies, renal
    studies assess BP, check for rising BP as Hct

Medications for CRF continued
  • Iron Salts
  • To treat anemia
  • Ferrous sulfate (Feosol, Feratab, Slow FE)
  • Replaces iron stores need for RBC development
  • Adult dose 100-200mg tid
  • Iron sucrose (Venofer)
  • Used to treat iron deficiency dute to chronic
  • Adult dose IV 5ml (100mg of elemental iron)
    given during dialysis, most will need 1000mg of
    elemental iron over 10 dialysis
  • Nursing Assessments Monitor blood studies, Hct,
    Hgb, total Fe, monthly. Assess bowel elimination
    for constipation

What is Dialysis?
  • Dialysis is a type of renal replacement therapy
    which is used to provide artificial replacement
    for lost kidney function due to acute or chronic
    kidney failure
  • It is a life support treatment, it does not cure
    acute or chronic renal failure
  • May be used for very sick clients who have
    suddenly lost kidney function
  • May be used for stable clients who have
    permanently lost kidney function
  • Healthy kidneys remove waste products (potassium,
    acid, urea) from the blood and they also remove
    excess fluid in the form of urine
  • Dialysis has to duplicate both of these functions
  • Dialysis waste removal
  • Ultrafiltration fluid removal

Principle of Dialysis
  • Dialysis works on the principle of diffusion of
    solutes along a concentration gradient across a
    semipermiable membrane
  • Blood passes on one side of the semipermeable
    membrane, and a dialysis fluid is passed on the
    other side
  • By altering the composition of the dialysis
    fluid, the concentrations of the undesired
    solutes (potassium, urea) in the fluid are low,
    but the desired solutes (sodium) are at their
    natural concentration found in healthy blood

Prescription for Dialysis
  • A prescription for dialysis is given by a
    physician who specializes in the kidney
  • The MD will set various parameters for the
  • Time and duration of the dialysis sessions
  • Size of the dialyzer
  • Rate of blood flow

2 Main Types of Dialysis
  • Hemodialysis
  • Peritoneal Dialysis

Adapted from National Institute of Diabetes and
Digestive and Kidney Diseases. National
Institute of Diabetes and Digestive and Kidney
Diseases. End-stage renal disease choosing a
treatment that's right for you. Available at
srd.htm. Accessed May 10, 2000.
What is Hemodialysis (HD)?
  • Clients blood is passed through a system of
    tubing (dialysis circuit) via a machine to a
    semipermeable membrane (dialyzer) which has the
    dialysis fluid running on the other side
  • The cleansed blood is then returned via the
    circuit back to the body
  • The dialysis process is very efficient (much
    higher than in the natural kidneys), which allows
    treatments to take place intermittently (usually
    3 times a week), but fairly large volumes of
    fluid must be removed in a single treatment which
    can be very demanding on a client

Side Effects of HD
  • The side effects are proportionate to the amount
    of fluid being removed
  • Decreased blood pressure
  • Fatigue
  • Chest pains
  • Leg cramps
  • Headaches
  • Electrolyte imbalance
  • NV
  • Reaction to the dialyzer
  • Air embolism

Complications of HD
  • Because HD requires access to the circulatory
    system, clients have a portal of entry for
    microbes, which could lead to infection
  • The risk of infection depends on the type of
    access used
  • Bleeding may also occur at the access site
  • Blood clotting was a serious problem in the past,
    but the incidence of this has decreased with the
    routine use of anticoagulants (Heparin is the
    most common)
  • Anticoagulants also come with their own risk of
    side effects and complications

Rare Complication of HD
  • On the rare occasion, a client may have a severe
    anaphylactic reaction
  • Sneezing
  • Wheezing
  • SOB
  • Back pain
  • Chest pain
  • Sudden death
  • This can be caused by the sterilant in the
    dialyzer or the material in the membrane itself

Three Types of Access for HD
  • IV catheter
  • Arteriovenous (AV) fistula
  • Synthetic graft
  • The type of access is influenced by factors such
    as expected time course of the clients renal
    failure and the condition of the clients
  • Some clients may have multiple accesses, usually
    because an AV fistula or a graft is maturing and
    an IV catheter is still being used

IV Catheter (Central Venous Catheter)
  • Consists of a plastic catheter with two lumens
    which is inserted into a large vein (vena cava
    via the internal jugular vein) to allow large
    flows of blood to be withdrawn from the first
  • The blood goes into the dialysis circuit, and is
    returned to the body via the second lumen
  • Non-tunneled
  • Tunneled
  • This type of access is used for clients who need
    rapid access for immediate dialysis
  • Clients who are likely to recover from ARF
  • Client with end-stage renal failure
  • Clients waiting for other sites to mature
  • This type of access is very popular for clients
    because it doesnt involve needles for each

Complications of an IV Catheter
  • Venous Stenosis
  • This is the abnormal narrowing of the blood
  • Because the catheter is a foreign body in the
    vessel, it often provokes an inflammatory
    reaction in the vein wall
  • This results in scarring and narrowing of the
    vein, often to the point where the vein occludes

AV Fistula
  • This access is recognized as the preferred access
  • To create a fistula a vascular surgeon joins an
    artery and a vein together
  • Since this bypasses the capillaries, blood flows
    at a very high rate through the fistula
  • This can be felt by placing a finger over a
    mature fistula (thrill)
  • Usually created in the non-dominant hand
  • It can be situated on the hand, forearm or the
  • It will take approximately 4-6 weeks to mature
  • During treatment, 2 needles are inserted, one to
    draw blood out of the body and the other to
    return blood to the body

Advantages of an AV Fistula
  • Decreased infection rate
  • Increased blood flow rates, therefore a more
    effective dialysis treatment
  • Decreased incidence of thrombosis

Complications of an AV Fistula
  • If an AV fistula has a very high flow rate and
    the vasculature that supplies the rest of the
    limb is poor, than a steal syndrome can occur
  • Blood that enters the limb is drawn into the
    fistula and returned to the general circulation
    without entering the capillaries of the limb
  • This results in cool extremities of the limb,
    cramping pains and possible tissue damage
  • Long term complications can be the development of
    a bulging in the wall of the vein (aneurysm)
  • The vessel wall is weakened by the repeated
    insertion of needles over time
  • Can be reduced by careful needling technique

AV Graft
  • This is much like a fistula, except an artificial
    vessel is used to join the artery and the vein
  • Grafts are used when clients own vasculature
    does not permit a fistula
  • An AV graft will mature much faster than an AV
    fistula, and it could be ready to use within days
    after formation

Complications of an AV Graft
  • AV grafts are at high risk for narrowing where
    the graft is sewn to the vein
  • As a result clotting or thrombosis may occur
  • As a foreign material is being placed in the
    body, there is a greater risk of infection

Equipment Needed for HD
  • The HD machine performs the function of pumping
    the patient's blood and the dialysate through the
  • The newest dialysis machines on the market are
    highly computerized and continuously monitor an
    array of safety-critical parameters, including
    blood and dialysate flow rates, blood pressure,
    heart rate, conductivity, pH, etc.
  • If any reading is out of normal range, an audible
    alarm will sound to alert the patient-care
    technician who is monitoring the patient.

Equipment Water System
  • An extensive water purification system is
    absolutely critical for HD
  • Since dialysis patients are exposed to vast
    quantities of water, which is mixed with the acid
    bath to form the dialysate, even trace mineral
    contaminants or bacterial endotoxins can filter
    into the patient's blood.
  • Because the damaged kidneys are not able to
    perform their intended function of removing
    impurities, ions that are introduced into the
    blood stream via water can build up to hazardous
    levels, causing numerous symptoms including death
  • For this reason, water used in HD is purified

Equipment The Dialyzer
  • The dialyzer, or artificial kidney, is the piece
    of equipment that actually filters the blood
  • The blood is run through a bundle of very thin
    capillary-like tubes, and the dialysate is pumped
    in a chamber bathing the fibers
  • The process mimics the physiology of the
    glomerulus and the rest of the nephron
  • Dialyzers come in many different sizes. A larger
    dialyzer will usually translate to an increased
    membrane area, and an increase in the amount of
    undesired solutes removed from the patient's
  • The nephrologist will prescribe the dialyzer to
    be used depending on the patient
  • Dialyzers are not shared between patients in the
    practice of reuse.

Peritoneal Dialysis
What is Peritoneal Dialysis (PD)?
  • Peritoneal dialysis works by using the body's
    peritoneal membrane, which is inside the abdomen,
    as a semi-permeable membrane.
  • A specially formulated dialysis fluid is
    instilled around the membrane, using an
    indwelling catheter, then dialysis can occur, by
  • Excess fluid can also be removed by osmosis, by
    altering the concentration of glucose in the
  • Dialysis fluid is instilled via a peritoneal
    dialysis catheter, which is placed in the
    patient's abdomen, running from the peritoneum
    out to the surface, near the navel
  • Peritoneal dialysis is typically done in the
    patient's home and workplace, but can be done
    almost anywhere

Advantages of PD
  • Can be done at home
  • Relatively easy for the client to learn
  • Easy to travel with, bags of solution are easy to
    take on holiday
  • Fluid balance is usually easier when the client
    is on PD than if the client is on HD

Disadvantage of PD
  • Requires a degree of motivation and attention to
    cleanliness while performing PD
  • There are a number of complications

Complications of PD
  • Peritoneal dialysis requires access to the
    peritoneum. As this access breaks normal skin
    barriers, and as people with renal failure
    generally have a slightly suppressed immune
    system, infection is a relatively common problem
  • Long term peritoneal dialysis can cause changes
    in the peritoneal membrane, causing it to no
    longer act as a dialysis membrane as well as it
    used to.
  • This loss of function can manifest as a loss of
    dialysis adequacy, or poorer fluid exchange (also
    known as ultrafiltration failure)
  • Fluid may leak into surrounding soft tissue,
    often the scrotum in males
  • Hernias are another problem that can occur due to
    the abdominal fluid load

Nursing Assessments
  • Before client is in the unit, look at the nurses
    notes from the treatment before
  • Any problems, will help nurse plan for the
    upcoming treatment
  • Look at the client
  • Strength
  • Gait
  • Whether client needs assistance
  • Color
  • Puffiness
  • Could be caused by excess fluid, too much to
    drink, more fluid should be taken off with each
    treatment, changes in voiding pattern (are they
    voiding less than they did last month)

Assessments Cont
  • Shortness of breath
  • Could indicate fluid around the lungs
  • Ask about SOB at night (does client have to sleep
    in a sitting position?)
  • Ask the client how they are feeling
  • The client is usually the best source of
  • Clients are in 3 times a week, dialysis nurses
    really get to know their clients
  • Evaluate access
  • Bruising, swollen, tender
  • Bruit listen with the stethoscope for a
    swishing sound of the blood, listen all the way
    up the arm
  • Thrill felt with the fingers, tells the nurse
    if the blood is flowing in the fistula (clients
    are told to feel for this at home when a fistula
    is first initiated)

Assessments During Treatment
  • Ask client how he/she feels
  • Dizziness, diaphoretic,
  • The machines automatically take BP and HR every
    30 minutes
  • Can program the machines to take it at whatever
    interval is necessary (every min, 10 min, 15 min)
  • Try to recognize a problem before it starts (ex.
    Hypovolemic shock)
  • Assess access site
  • Watch trend of BP
  • It usually gradually decreases throughout the
    course of the treatment, but look for sudden or
    drastic drops
  • Assess access site
  • Bleeding, swelling, tenderness

Nursing Interventions
  • If client comes in with shortness of breath,
    offer O2 which can be kept on for the full
    treatment if necessary
  • Comfort
  • Clients are sitting in the same chair for up to
    four hours
  • Offer extra pillows, some clients have special
    back pillow they leave in the unit
  • Ensure TV and audio is working properly

Nursing Interventions Cont
  • If the blood pressure is dropping too quickly
  • Slow or stop fluid removal for a time period
  • The machines are constantly being adjusted
    throughout the course of the treatment depending
    on the BP
  • If the BP drops suddenly 200-300cc of normal
    saline can be given to balance fluid levels
  • Usually, more fluid will be taken off at the
    beginning of the treatment, this will allow the
    client to feel better at the end
  • If the client is elderly, fluid removal starts
    slowly to ease them into the treatment

Responsibilities of Nursing StaffPrior to
  • Ensure client is ready to sit for up to four
  • Encourage client to use washroom before arriving
    to the unit
  • Try to avoid laxatives if possible before
  • Ensure client has eaten meal prior to treatment

Responsibilities of Nursing StaffAfter Dialysis
  • A dialysis nurse will give unit leader or primary
    nurse a verbal report of treatment
  • Any complications during treatment
  • Check BP standing and sitting
  • Assess access site
  • Encourage client to rest
  • Avoid treatments or physio for a couple of hours
    if possible
  • Watch fluid intake
  • Be aware if client is on fluid restriction
  • Check thrill and bruit
  • Do not take a BP on access arm
  • Do not take blood from access arm

Questions? Thank you for listening.
Write a Comment
User Comments (0)